Surgical treatments for esophageal cancers.

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the role of the nurse in preparation of esophageal resection (ER); the management of patients who develop high-grade dysplasia after having undergone Nissen fundoplication; the trajectory of care for the patient with esophageal cancer; the influence of the site of tumor in the choice of treatment; the best location for esophagogastrostomy; management of chylous leak after esophagectomy; the optimal approach to manage thoracic esophageal leak after esophagectomy; the choice for operational approach in surgery of cardioesophageal crossing; the advantages of robot esophagectomy; the place of open esophagectomy; the advantages of esophagectomy compared to definitive chemoradiotherapy; the pathologist report in the resected specimen; the best way to manage patients with unsuspected positive microscopic margin after ER; enhanced recovery after surgery for ER: expedited care protocols; and long-term quality of life in patients following esophagectomy.

Optimization methods for the operating room management under uncertainty: stochastic programming vs. decomposition approach

The operating theatres are the engine of the hospitals; proper management of the operating rooms and its staff represents a great challenge for managers and its results impact directly in the budget of the hospital. This work presents a MILP model for the efficient schedule of multiple surgeries in Operating Rooms (ORs) during a working day. This model considers multiple surgeons and ORs and different types of surgeries. Stochastic strategies are also implemented for taking into account the uncertain in surgery durations (pre-incision, incision, post-incision times). In addition, a heuristic-based methods and a MILP decomposition approach is proposed for solving large-scale ORs scheduling problems in computational efficient way. All these computer-aided strategies has been implemented in AIMMS, as an advanced modeling and optimization software, developing a user friendly solution tool for the operating room management under uncertainty.

Análisis del comportamiento a fatiga de uniones adhesivas de acero recubierto

Los adhesivos se conocen y han sido utilizados en multitud de aplicaciones a lo lago de la historia. En la actualidad, la tecnología de la adhesión como método de unión de materiales estructurales está en pleno crecimiento. Los avances científicos han permitido comprender mejor los fenómenos de adhesión, así como, mejorar y desarrollar nuevas formulaciones poliméricas que incrementan el rango de aplicaciones de los adhesivos. Por otro lado, el desarrollo de nuevos materiales y la necesidad de aligerar peso, especialmente en el sector transporte, hace que las uniones adhesivas se introduzcan en aplicaciones hasta ahora reservadas a otros sistemas de unión como la soldadura o las uniones mecánicas, ofreciendo rendimientos similares y, en ocasiones, superiores a los aportados por estas. Las uniones adhesivas ofrecen numerosas ventajas frente a otros sistemas de unión. En la industria aeronáutica y en automoción, las uniones adhesivas logran una reducción en el número de componentes (tales como los tornillos, remaches, abrazaderas) consiguiendo como consecuencia diseños más ligeros y una disminución de los costes de manipulación y almacenamiento, así como una aceleración de los procesos de ensamblaje, y como consecuencia, un aumento de los procesos de producción. En el sector de la construcción y en la fabricación de equipos industriales, se busca la capacidad para soportar la expansión y contracción térmica. Por lo tanto, se usan las uniones adhesivas para evitar producir la distorsión del sustrato al no ser necesario el calentamiento ni la deformación de las piezas cuando se someten a un calentamiento elevado y muy localizado, como en el caso de la soldadura, o cuando se someten a esfuerzos mecánicos localizados, en el caso de montajes remachados. En la industria naval, se están desarrollando técnicas de reparación basadas en la unión adhesiva para distribuir de forma más uniforme y homogénea las tensiones con el objetivo de mejorar el comportamiento frente a fatiga y evitar los problemas asociados a las técnicas de reparación habituales de corte y soldadura. Las uniones adhesivas al no requerir importantes aportes de calor como la soldadura, no producen modificaciones microestructurales indeseables como sucede en la zona fundida o en la zona afectada térmicamente de las uniones soldadas, ni deteriora los recubrimientos protectores de metales de bajo punto de fusión o de naturaleza orgánica. Sin embargo, las uniones adhesivas presentan una desventaja que dificulta su aplicación, se trata de su durabilidad a largo plazo. La primera causa de rotura de los materiales es la rotura por fatiga. Este proceso de fallo es la causa del 85% de las roturas de los materiales estructurales en servicio. La rotura por fatiga se produce cuando se somete al material a la acción de cargas que varían cíclicamente o a vibraciones durante un tiempo prolongado. Las uniones y estructuras sometidas a fatiga pueden fallar a niveles de carga por debajo del límite de resistencia estática del material. La rotura por fatiga en las uniones adhesivas no se produce por un proceso de iniciación y propagación de grieta de forma estable, el proceso de fatiga va debilitando poco a poco la unión hasta que llega un momento que provoca una rotura de forma rápida. Underhill explica este mecanismo como un proceso de daño irreversible de los enlaces más débiles en determinados puntos de la unión. Cuando se ha producido el deterioro de estas zonas más débiles, su área se va incrementando hasta que llega un momento en que la zona dañada es tan amplia que se produce el fallo completo de la unión. En ensayos de crecimiento de grieta realizados sobre probetas preagrietadas en viga con doble voladizo (DCB), Dessureault identifica los procesos de iniciación y crecimiento de grietas en muestras unidas con adhesivo epoxi como una acumulación de microfisuras en la zona próxima al fondo de grieta que, luego, van coalesciendo para configurar la grieta principal. Lo que supone, igualmente, un proceso de daño del adhesivo en la zona de mayor concentración de tensiones que, posteriormente, conduce al fallo de la unión. La presente tesis surge con el propósito de aumentar los conocimientos existentes sobre el comportamiento a fatiga de las uniones adhesivas y especialmente las realizadas con dos tipos de adhesivos estructurales aplicados en aceros con diferentes acabados superficiales. El estudio incluye la obtención de las curvas de tensión frente al número de ciclos hasta el fallo del componente, curvas SN o curvas de Wöhler, que permitirán realizar una estimación de la resistencia a la fatiga de un determinado material o estructura. Los ensayos de fatiga realizados mediante ciclos predeterminados de carga sinusoidales, de amplitud y frecuencia constantes, han permitido caracterizar el comportamiento a la fatiga por el número de ciclos hasta la rotura, siendo el límite de fatiga el valor al que tiende la tensión cuando el número de ciclos es muy grande. En algunos materiales, la fatiga no tiende a un valor límite sino que decrece de forma constante a medida que aumenta el número de ciclos. Para estas situaciones, se ha definido la resistencia a la fatiga (o límite de resistencia) por la tensión en que se produce la rotura para un número de ciclos predeterminado. Todos estos aspectos permitirán un mejor diseño de las uniones y las condiciones de trabajo de los adhesivos con el fin de lograr que la resistencia a fatiga de la unión sea mucho más duradera y el comportamiento total de la unión sea mucho mejor, contribuyendo al crecimiento de la utilización de las uniones adhesivas respecto a otras técnicas. ABSTRACT Adhesives are well-known and have been used in many applications throughout history. At present, adhesion bonding technology of structural materials is experiencing an important growth. Scientific advances have enabled a better understanding of the phenomena of adhesion, as well as to improve and develop new polymeric formulations that increase the range of applications. On the other hand, the development of new materials and the need to save weight, especially in the transport sector, have promote the use of adhesive bonding in many applications previously reserved for other joining technologies such as welded or mechanical joints, presenting similar or even higher performances. Adhesive bonding offers many advantages over other joining methods. For example, in the aeronautic industry and in the automation sector, adhesive bonding allows a reduction in the number of components (such as bolts, rivets, clamps) and as consequence, resulting in lighter designs and a decrease in handling and storage costs, as well as faster assembly processes and an improvement in the production processes. In the construction sector and in the industrial equipment manufacturing, the ability to withstand thermal expansion and contraction is required. Therefore, adhesion bonding technology is used to avoid any distortion of the substrate since this technology does not require heating nor the deformation of the pieces when these are exposed to very high and localized heating, as in welding, or when are subjected to localized mechanical stresses in the case of riveted joints. In the naval industry, repair techniques based in the adhesive bonding are being developed in order to distribute stresses more uniform and homogeneously in order to improve the performance against fatigue and to avoid the problems associated with standard repair techniques as cutting and welding. Adhesive bonding does not require the use of high temperatures and as consequence they do not produce undesirable microstructural changes, as it can be observed in molten zones or in heat-affected zones in the case of welding, neither is there damage of the protective coating of metals with low melting points or polymeric films. However, adhesive bonding presents a disadvantage that limits its application, the low longterm durability. The most common cause of fractures of materials is fatigue fracture. This failure process is the cause of 85% of the fracture of structural materials in service. Fatigue failure occurs when the materials are subjected to the action of cyclic loads or vibrations for a long period of time. The joints and structures subjected to fatigue can fail at stress values below the static strength of the material. Fatigue failure do not occurs by a static and homogeneous process of initiation and propagation of crack. The fatigue process gradually weakens the bond until the moment in which the fracture occurs very rapidly. Underhill explains this mechanism as a process of irreversible damage of the weakest links at certain points of the bonding. When the deterioration in these weaker zones occurs, their area increase until the damage zone is so extensive that the full failure of the joint occurs. During the crack growth tests performed on precracked double-cantilever beam specimen, (DCB), Dessureault identified the processes of crack initiation and growth in samples bonded with epoxy adhesive as a process of accumulation of microcracks on the zone near the crack bottom, then, they coalesced to configure the main crack. This is a damage process of the adhesive in the zone of high stress concentration that leads to failure of the bond. This thesis aims to further the understanding of the fatigue behavior of the adhesive bonding, primarily those based on two different types of structural adhesives used on carbon-steel with different surface treatments. This memory includes the analysis of the SN or Wöhler curves (stress vs. number of cycles curves up to the failure), allowing to carry out an estimation of the fatigue strength of a specific material or structure. The fatigue tests carried out by means of predetermined cycles of sinusoidal loads, with a constant amplitude and frequency, allow the characterisation of the fatigue behaviour. For some materials, there is a maximum stress amplitude below which the material never fails for any number of cycles, known as fatigue limit. In the other hand, for other materials, the fatigue does not tend toward a limit value but decreases constantly as the number of cycles increases. For these situations, the fatigue strength is defined by the stress at which the fracture occurs for a predetermined number of cycles. All these aspects will enable a better joint design and service conditions of adhesives in order to get more durable joints from the fatigue failure point of view and in this way contribute to increase the use of adhesive bonding over other joint techniques.

Addresses and other papers,

The early history of practical anatomy.--The history of the Philadelphia school of anatomy and its relation to medical teaching.--Our recent debts to vivisection.--Recent progress in surgery.--The new era in medicine and its demands upon the profession and the college.--The real rewards of medicine.--Medicine as a career for educated men.--Vivisection and brain surgery.--Medical education.--The advantages of an academic training for a medical career.--Literary methods in medicine.--Address at the unveiling of the statue of the late Prof. Samuel D. Gross, M.D.--Semicentennial address in surgery before the American medical association.--The debt of the public to the medical profession.--The endowment of medical colleges.--The ideal physician.--Address at the Royal college of surgeons of England at the conferring of honorary degrees at the centenary celebration of the granting of its present charter.--The progress of surgery in the nineteenth century.--The mission of a medical college.--The duties and responsibilities of trustees of public medical institutions.--The qualities essential to success in medicine.--The cheerfulness of death.--The need for increased endowments for medical instruction.--Age and youth in medicine.--Surgical reminiscences of the civil war.

Collected papers of the Mayo Clinic and the Mayo Foundation.

Mode of access: Internet.

A smart surgical robotic for cochlear implantation

In this paper a surgical robotic device for cochlear implantation surgery is described that is able to discriminate tissue interfaces and other controlling parameters ahead of a drill tip. The advantage in surgery is that tissues at interfaces can be preserved. The smart tool is able to control interaction with respect to the flexing tissue to avoid penetration control the extent of protrusion with respect to the real-time position of the tissue. To interpret drilling conditions, and conditions leading up to breakthrough at a tissue interface, the sensing scheme used enables discrimination between the variety of conditions posed in the drilling environment. The result is a robust fully autonomous system able to respond to tissue type, behaviour and deflection in real-time. The paper describes the robotic tool that has been designed to be used in the surgical environment where it has been used in the operating room.

Development and Characterization of Monovalent and Bivalent RNA Aptamers Targeting the Common Pathway of Coagulation

Anticoagulant agents are commonly used drugs to reduce blood coagulation in acute and chronic clinical settings. Many of these drugs target the common pathway of coagulation because it is critical for thrombin generation and disruption of this portion of the pathway has profound effects on the hemostatic process. Currently available drugs for these indications struggle with balancing desired activity with immunogenicity and poor reversibility or irreversibility in the event of hemorrhage. While improvements are being made with the current drugs, new drugs with better therapeutic indices are needed for surgical intervention and chronic indications to prevent thrombosis from occurring.

A class of therapeutics known as aptamers may be able to meet the need for safer anticoagulant agents. Aptamer are short single-stranded RNA oligonucleotides that adopt specific secondary and tertiary structures based upon their sequence. They can be generated to both enzymes and cofactors because they derive their inhibitory activity by blocking protein-protein interactions, rather than active site inhibition. They inhibit their target proteins with a high level of specificity and bind with high affinity to their target. Additionally, they can be reversed using two different antidote approaches, specific oligonucleotide antidotes, or with cationic, “universal” antidotes. The reversal of their activity is both rapid and durable.

The ability of aptamers to be generated to cofactors has been conclusively proven by generating an aptamer targeting the common pathway coagulation cofactor, Factor V (FV). We developed two aptamers with anticoagulant ability that bind to both FV and FVa, the active cofactor. Both aptamers were truncated to smaller functional sizes and had specific point mutant aptamers developed for use as controls. The anticoagulant activity of both aptamer-mutant pairs was characterized using plasma-based clotting assays and whole blood assays. The mechanism of action resulting in anticoagulant activity was assessed for one aptamer. The aptamer was found to block FVa docking to membrane surfaces, a mechanism not previously observed in any of our other anticoagulant aptamers.

To explore development of aptamers as anticoagulant agents targeting the common pathway for surgical interventions, we fused two anticoagulant aptamers targeting Factor X and prothrombin into a single molecule. The bivalent aptamer was truncated to a minimal size while maintaining robust anticoagulant activity. Characterization of the bivalent aptamer in plasma-based clotting assays indicated we had generated a very robust anticoagulant therapeutic. Furthermore, we were able to simultaneously reverse the activity of both aptamers with a single oligonucleotide antidote. This rapid and complete reversal of anticoagulant activity is not available in the antithrombotic agents currently used in surgery.

Intervención cognitivo-conductual para el control de ansiedad ante la biopsia insicional en pacientes con cáncer de mama

Oncological patients are submitted to invasive exams in order to obtain an accurate diagnosis; these procedures may cause maladaptative reactions (fear, anxiety and pain). Particularly in breast cancer, the most common diagnose technique is the incisional biopsy. Most of the patients are unaware about the procedure and for that reason they may focus their thoughts on possible events such as pain, bleeding, the anesthesia, or the later surgical wound care. Anxiety and pain may provoke physiological, behavioral and emotional complications, and because of this reason, the Behavioral Medicine trained psychologist takes an active role before and after the biopsy. The aim of this study was to evaluate the effect of a cognitive-behavioral program to reduce anxiety in women submitted to incisional biopsy for the first time. There were 10 participants from the Hospital Juárez de México, Oncology service; all of them were treated as external patients. The intervention program focused in psycho-education and passive relaxation training using videos, tape-recorded instructions and pamphlets. Anxiety measures were performed using the IDARE-State inventory, and a visual-analogue scale of anxiety (EEF-A), and the measurement of blood pressure and heart rate). Data were analyzed both intrasubject and intersubject using the Wilcoxon test (p≤0.05). The results show a reduction in anxiety (as in punctuation as in ranges) besides, a reduction in the EEF-A.

Novo conceito de juntas adesivas utilizando laminados de fibras e metal

Devido às necessidades da indústria atual é cada vez mais importante a utilização de métodos de união de materiais distintos. A utilização de adesivos no processo de produção de materiais compósitos tem uma grande aplicação, uma vez que permite ligar os diferentes materiais e ainda reduzir significativamente o peso do conjunto. Este trabalho teve como principal objetivo aumentar a resistência à delaminação de materiais compósitos no sentido da espessura, concretamente dos plásticos reforçados com fibras de carbono (CFRP), através da utilização de placas da liga de alumínio 2024-T3. Este conceito é muito semelhante ao utilizado nos laminados por fibras e metal (LFM) para aumentar a sua resistência à delaminação. Pretendeu-se também a identificação da configuração da junta que apresenta melhores resultados, comparativamente à junta de referência composta apenas por CFRP. Inicialmente, produziram-se apenas juntas de CFRP que foram utilizadas como comparação com os laminados de fibras e metal. Com o objetivo de melhorar a adesão entre os CFRP e a liga de alumínio, foram realizados três tratamentos superficiais diferentes, nomeadamente a lixagem, a anodização e o ataque com ácido. Posteriormente, foram produzidas as juntas com as seguintes configurações: CFRP-AL-CFRP, CFRP-AL-CFRP-AL-CFRP e AL-CFRP-AL. A realização deste trabalho permitiu concluir que com a adição de placas de alumínio, se conseguiu um melhoramento da resistência à delaminação das fibras de carbono e ainda um aumento da resistência específica no sentido da sua espessura. A JSS com a configuração AL-CFRP-AL e com comprimento de sobreposição de 50 mm foi a configuração que apresentou uma força de rotura mais elevada, ou seja, uma maior resistência à delaminação, comparativamente à junta de referência e às restantes configurações em estudo. A falha coesiva verificada perto da interface da junta AL-CFRP-AL, pode ser devida ao elevado comprimento de sobreposição e às diferentes elasticidades do alumínio e do CFRP, o que naturalmente levou a elevadas tensões localizadas nas extremidades da junta. Os resultados demostraram que é possível aumentar a resistência transversal do compósito utilizando uma placa de alumínio.